What is RAF and HCC Coding?

Hierarchical condition category (HCC) coding is a risk-adjustment model originally designed to estimate future health care costs for patients. Along with demographic factors (such as age and gender), insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.

The HCC/RAF (Risk Adjustment Factor) point system is a “shadow” calculation that affects every physician’s reimbursement, no matter what goes on the bill. The HCC/RAF regulation assigns a point value to a relatively small number of ICD diagnosis codes that indicate serious disease.

Why Should Providers Care about RAF’s?

  1. Helps to identify patients who may achieve better outcomes through individualized support services such as Care Management.
  2. Ensures that your patients receive the appropriate level of care while supporting your efforts to coordinate their care.
  3. Risk Adjustment supports your practice in meeting the reporting requirements of ICD-10-CM codes, including records accuracy and timely reporting of claims and encounter data.
  4. Effective risk adjustment coding helps to streamline your claims process, which may result in faster reimbursement.

MEAT the best practice model for documentation.

Monitor: signs, symptoms, disease progression, disease regression, etc.

Evaluate: test results, medication effectiveness, and response to treatment

Assess/Address: ordering tests, discussion, review records, counseling

Treat: medications, therapies, other modalities

Learn more about our HCC & Star Measures Specialists

Key Things to do to Improve HCC Coding:

  1. Having an accurate problem list-Remove any duplicated info from EMR and identify and implement a diagnosis preference list to include HCC suffix codes and RAF values as well as prioritize results.
  2. Ensuring patients are seen in each calendar year- Frontload visits from patients who have not been seen in the calendar year yet to make sure they are being seen.
  3. Tracking performance and identifying opportunities-Reviewing unresolved persistent conditions for specific populations.